A nurse is talking with a client who has schizophrenia. Suddenly the client states, “I’m frightened. Do you hear that? The voices are telling me to do terrible things.” Which of the following responses by the nurse is appropriate?

Choice A reason: Asking “What are the voices telling you to do?” is an appropriate response because it allows the nurse to assess the content of the hallucinations and determine if the client is at risk of harming themselves or others. This approach shows empathy and concern while gathering important information for the client’s safety. Choice B reason: Telling the client “You need to understand that there are no voices” dismisses the client’s experience and can increase their distress. It is important to acknowledge the client’s feelings and perceptions, even if they are not based in reality. Choice C reason: Asking “Why do you think you are hearing the voices?” may not be helpful in the moment of distress. The client may not be able to provide a rational explanation for their hallucinations, and this question could increase their confusion and anxiety. Choice D reason: Telling the client “You need to tell the voices to leave you alone” may not be effective, as the client may not have the ability to control their hallucinations. It is more important to assess the content of the hallucinations and provide support.